Active Exchange of CSF for Rapid Removal of Blood in Hemorrhagic Stroke: Multicenter Experience in 40 Patients

Background: Spontaneous intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) may present with intraventricular hemorrhage (IVH). Prior studies show IVH correlates with increased mortality and morbidity. Neuroinflammation from blood organization in cerebrospinal fluid (CSF) contributes to poor outcomes. Objective: We hypothesized that active external ventricular drainage (EVD) would accelerate blood removal, reducing adverse events. Study sites used double-lumen EVDs with active irrigation and intracranial pressure control via passive drainage. Material and Methods: Data from 6 centers in the EU and USA were analyzed. Forty patients in total were included: 21 with SAH, 13 with spontaneous ICH-related IVH, and 6 with vascular anomaly-related hemorrhage. Blood removal was assessed via CT imaging. Shunt dependency in SAH patients was calculated using CHESS scores. Results: Blood removal via active EVD was safely achieved. Removal pace correlated with irrigation volume. All 13 ICH patients had median IVH clearance of 91.3% (range: 0.7%–100%) over 7.6 days. SAH patients showed lower shunt dependency (2) than expected (11) per CHESS scores and literature. The vascular anomaly group had median IVH clearance of 91.3% over 8 days. No CSF exchange-related infections occurred. Conclusions: Accelerated blood removal from the CSF system via active EVD is safe and feasible. Active irrigation reduced adverse events. Blood clearance is strongly linked to irrigation rate. Prospective trials are needed to identify the patient population most likely to benefit from CSF exchange during hemorrhagic stroke treatment.